The Surgeon’s Plan: Tympanic Membrane Perforation

By the nineteenth century, Sir Astley Paston Cooper (1768-1841), surgeon to Guy’s Hospital, outlined his observation that puncture of the tympanic membrane could be effective in draining out collections of fluid in the middle ear, and hence, improve a particular type of deafness.

Sir Astley Cooper

Cooper’s work was inspired in part by his friend Sir Everard Home (1756-1832), surgeon to St. George’s Hospital and son-in-law of surgeon John Hunter (1728-1793). On 7 November 1799, Home read a paper before the Royal Society describing how comparative anatomy led him to outline the radial fibres of the tympanic membrane, emphasizing how the “muscular action…may conduce to account for certain phanomena in the sense of hearing.”[1] In particular, Home emphasized that while it “is true that the membrane tympani is stretched and relaxed by the action of the muscles of the malleus…It is stretched, in order to bring the radiated muscle of the membrane itself into a state capable of acting, and of giving those different degrees of tension to the membrane” suitable for hearing.[2] In a letter to Home, read before the Royal Society, Cooper remarked on whether “the loss of power which the organ of hearing would sustain by perforating the membrane tympani,” of a human ear, as only dogs have previously been made the subject of these trials, as exemplified by the work of British physician Thomas Willis (1621-1675) and Valsalva. Observing the ear of two of his patients—a Mr. P., twenty year old medical student at St. Thomas’s Hospital, who had been subjected to vicious attacks of inflammation and suppuration in his left hear since childhood, and Mr. A., another gentleman professing similar complaints—Cooper contended that it “was evident from these experiments that the membrana tympani of each ear was incomplete, and that the air issued from the mouth, but the Eustachian tube, through an opening in that membrane, and escaped by the external meatus.”[3] Cooper’s observations claimed that in cases where the membrana tympani had been destroyed, air was still able to produce the necessary effect for perfect hearing.

The likelihood that tympanic membrane perforation did not necessarily result in a loss of hearing and immediate enthusiasm for the procedure led Cooper to deliver a second paper before the Royal Society, outlining a clear methodology for the procedure and describing its success.[4] Remarking on the “prejudice” against medical intervention, Cooper writes:

A prejudice has prevailed, that the ear is too delicate an organ to be operated upon, or, as it is commonly expressed, tampered with; and thousands have thus remained deaf for the rest of their lives, who might have been restored to hearing, had proper assistance been easily applied. But this prejudice, it is hoped, will now be done away; since it appears, that part which had been thought most essential to hearing, viz., the membrana tympani may be injured by disease, or may be broken by violence, without a deprivation of the sense of hearing, and that, even when this membrane is entirely destroyed, another is found to perform its functions; so that the powers of the organ have still been, in a considerable degree, preserved.[5]

Cooper examined more than twenty cases of deafness coupled with damaged membrana tympani, which he insisted often arises from an obstruction in the Eustachian tube. The operation Cooper proposed to cure for this deafness consisted in puncturing the membrana tympani, which he documented in several cases: “The operation to remedy the species of deafness here described, consists in passing into the ear a canula, of the size of a common probe, in which a trocar is concealed; the canula is to rest upon the membrana tympani, and the trocar is then to be thrust through the membrane.”[6] The operation, however, was performed blind, as Cooper’s sole motives for implementing the procedure was based on Eustachian tube obstruction.[7] For his observations, in 1802 Cooper was bestowed the Copley medal by the Royal Society, and in 1805 was elected a Fellow.

The immediate response from Cooper’s papers led to tympanic membrane perforation becoming a popular procedure, used as a catch-all “cure” for all cases of deafness, despite Cooper’s claims that it should be carefully adhered to his strict selection criteria. Christian Michaelis, for instance, Professor of anatomy and surgery in Marburg, performed the operation on sixty-three patients in 1804 alone.[8] Many “non-medically trained” practitioners also promoted the use of the procedure for their patients, and its “injudicious overuse inevitably led to it falling from favour, as the majority of patients did not gain any benefit, and many presumably lost further hearing as a result of blind tympanic membrane perforation.”[9]

NOTES

[1] Everard Home, “The Croonian Lecture: On the Structure and Uses of the Membrana Tympani of the Ear,” Philosophical Transactions of the Royal Society of London 90 (1800): 1-21; 1.

[3] Astley Cooper, “Observations on the Effects Which Take Place from the Destruction of the Membrana Tympani of the Ear,” Philosophical Transactions of the Royal Society of London, 90 (1800): 151-160; 153.

[4] Astley Cooper, “Farther Observations on the Effects Which Take Place from the Destruction of the Membrana Tympani of the Ear; With an Account of an Operation for the removal of a Particular Species of Deafness,” Philosophical Transactions of the Royal Society of London 91 (1801): 435-450.